Provider Demographics
NPI:1396926929
Name:SABRA, SAMIRA LAILA
Entity type:Individual
Prefix:
First Name:SAMIRA
Middle Name:LAILA
Last Name:SABRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SAMIRA
Other - Middle Name:LAILA
Other - Last Name:SABRA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7035 PERRY TERRACE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209
Mailing Address - Country:US
Mailing Address - Phone:917-816-8652
Mailing Address - Fax:
Practice Address - Street 1:120 COURT STREET
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201
Practice Address - Country:US
Practice Address - Phone:718-643-2146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-26
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049836183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02497056Medicaid